Introduction
A population-based survey conducted in Cambodia in 2007 by the Ministry of Health found self-reported rates of high blood pressure of about 50% were significantly higher than the actual prevalence of high blood pressure of about 12% (Saphonn & Prak, 2008). This raised a question about what the term used for high blood pressure by health professionals meant to patients, and whether the surveyed population had a different perspective from health professionals. One of the co-authors (JPL) was concerned that terms used for hypertension in Khmer, the Cambodian language, resulted in the higher perception of hypertension as compared to its much lower measured prevalence. These terms, which suggest that hypertension is an illness related to blood volume—and not pressure—may influence patients’ understanding of the disease. If so, such confusion may increase the risk of poorer health outcomes if adequate education about the disease is not imparted.
The Khmer terms for hypertension used by interpreters and patients in the Seattle area are the same as those in Cambodia. Therefore we explored whether the terminology used may be a source of confusion for Cambodian immigrants.
Methods
Interviews were conducted with five Cambodian medical interpreters, nine Cambodian patients (all diabetic), and a Cambodian physician-assistant and a non-Cambodian physician who practice in the Seattle area and work with Cambodian patients. The patients receive medical care at a number of different Seattle area clinics. The patients who were interviewed were over 50 years of age and included recent immigrants and those who have been in the U.S. 10 years or more. All patients were fluent Khmer speakers and most were limited English proficient.
Findings
Khmer Terminology
Chjoomnew lew cheeum is the medical term used by medical providers in Cambodia when speaking to patients about hypertension. This term translates literally as the “disease of having too much blood.”
Lew cheeum and laang cheeum are the lay terms for hypertension used by Cambodians both in the U.S. and in Cambodia. Laang cheeum also refers to a Cambodian idiom that translates as “high blood” or “rising blood to the face,” a folk illness which describes blushing or anger, making the concept of hypertension confusing among patients who do not understand laang cheeum in the context of hypertension.
Neither the medical nor lay terms used in Cambodia indicate that pressure is involved, but rather that volume is the issue. Further reinforcing the perception that chjoomnew lew cheeum (high blood pressure) is caused by a large volume of blood (instead of the force of blood against the artery walls) are the two words that are used interchangeably by health care providers in Cambodia to describe measuring blood pressure: thleung, “to weigh” and voas, “to measure length, width, or height.” These terms all suggest the measurement of something with physical properties.
Patients and interpreters interviewed for this article in the Seattle area concur that the lay and medical terms that they use in the U.S. are the same as those used in Cambodia. All patients interviewed stated that when first diagnosed with hypertension they initially believed that hypertension was related to blood volume. At the time of the interviews, patients expressed confusion about the symptoms of high blood pressure and many indicated that they do not take medication prescribed for hypertension as directed.
See accompanying table in sidebar to further explore Khmer terms related to hypertension discussed in the interviews.
Patient Beliefs about Causes and Symptoms of Hypertension
Patients who were interviewed believe that high blood pressure causes symptoms such as malaise, tightening of the neck veins/vessels, headaches, inability to eat or to sleep, feeling that the neck is weak or tired, headache, blurry vision, weakness, dizziness, painful or fatigued hands, nausea, and ringing in the ears. It is believed that, conversely, these same symptoms can increase blood pressure.
Here is a commonly reported scenario by the patients who were interviewed: A patient may see the doctor about symptoms perceived to be caused by, or causing, hypertension. In the event that the patient is diagnosed with hypertension at that visit, the patient may consequently associate the perceived symptoms with the disease. The patient will then begin to use a symptom-based approach by checking his or her blood pressure every time he or she experiences symptoms perceived to be caused by high blood pressure.
See accompanying table in sidebar to further explore Khmer terms for symptoms discussed in the interviews.
Patient Beliefs about Treatment for Hypertension
Patients unanimously said that to treat hypertension, it is important to take medication, exercise, and avoid eating too much salt and too much oil. However, some reported that they were likely, at least sometimes, to adhere to a symptom-based approach to determine when to take medication. For example, some patients said they will break up the dose prescribed in order to spread out the medication over the course of a day because they perceive that spreading the dose out will help to prevent blood pressure from rising. Many reported that they can anticipate that their blood pressure will rise at certain times of the day or after certain activities.
Some patients mentioned that initially they did not take medication properly because they had assumed that they did not need it daily and so skipped taking medication until symptoms became more severe or reoccurred. One patient initially thought that hypertension could be cured by taking more than the prescribed amount of medication and consequently overdosed on his medication, leading to hospitalization. Patients claim that they learned to take their medication every day, exercise, and eat less salt. They believe that these interventions are treatments for hypertension; after following through with these interventions, they don’t understand why their blood pressure is still high.
Patients perceive medication as the most important thing to follow through with, but also believe that exercising (common exercises are walking and stretching), and eating less salt are essential to aiding the effectiveness of hypertension medication. Several patients and interpreters mentioned how important stress management is to controlling symptoms of high blood pressure. Patients shared that things that make them tense include worrying about children’s welfare, missing relatives who are far away, and worrying a lot about hypertension. Patients reported that they relieve tension or stress by sitting down to relax and taking walks. A few patients stated that hypertension is a disease that “affects everything” and “is also a disease that is affected by everything.” Examples of “everything” are family, work, life, and level of happiness.
Traditional Treatment: Coining
Some of the patients use coining to help treat hypertension. Coining is a traditional medical treatment used by some Cambodians to relieve symptoms of headaches, dizziness, fevers, fainting, chills, and “not feeling well.” Coining involves first rubbing heated oil on the skin and then rubbing a coin over the skin until a red mark is visible. When a person is known to have the above symptoms without knowing the causes of the symptoms, the person is said to have “wind illness.” These symptoms are lumped together as symptoms that indicate a blockage in the internal circulation of air or wind, or too much air or wind. For more information about wind illness – a culture-bound syndrome – and coining, see Ethnographic Study among Seattle Cambodians: Wind Illness. As long as symptoms persist, Cambodians will continue to coin to feel better. Coining is used as treatment, not as a cure.
The symptoms of wind illness and patients’ perceived symptoms of hypertension are very similar. Most patients with hypertension replace coining with hypertension medication, exercise, and a low-salt diet after learning that the symptoms they associated with wind illness can be perceived as symptoms of hypertension. Many of the patients fear that coining will lead to bursting of blood vessels because of the abrasiveness and pressure of scraping and pressing a coin against the skin. Subsequently, many patients have relied solely on medication, diet, and exercise or rubbing/massaging the neck with wind oils to help with circulating extra air out of the body. One patient continues to coin whenever he experiences symptoms because it “feels better” after coining. An alternative way to remove air from the body is by cupping, another traditional Cambodian treatment; however, no one interviewed spoke about using this method. One of the co-authors (SS) has known Cambodians in the Seattle area who have used this method.
Suggestions by Interpreters and Patients regarding Terms
There was a significant amount of discussion with interpreters and patients about the Khmer terms for hypertension and if attempts should be made to revise terms, possibly by inserting the word pressure – sompeat in Khmer – into the terms. Patients and interpreters agree that the word sompeat is most often used in the context of pressure outside of the body such as air pressure in the atmosphere, air pressure in a tire, or to pressure somebody. Therefore, some interpreters suggested that the word force – komlang – would be a better word to add. Overall, there were mixed opinions about revising the terms.
Suggestions for Education about Hypertension
Patients and interpreters offered the following suggestions for education:
- Provide one-on-one education at the provider’s office, or at the patient’s home. At-home education could be done by Cambodian “health advocates.”
- Conduct small group, discussion-based workshops at Buddhist temples (15-20 participants, offered after prayers to help increase attendance). Small groups are recommended in order to make asking questions and participating in discussion easier.
- Frame workshops as talks for “patient health” versus “disease.”
- Workshops should be taught by Cambodian health educators.
- Create videos in Khmer about hypertension that illustrate the mechanics of hypertension. Tailor the videos to address Cambodian beliefs about hypertension.
- Provide visual aids for small group or one-on-one education.
- Provide incentives for attending workshops.
Recommendations for Providers
- Discuss with Cambodian patients the difference between the folk illness “high blood” and hypertension. Address the possible confusion related to the overlapping Khmer terms.
- Because the Khmer terms for high blood pressure are not likely to change, there will continue to be confusion about volume versus pressure. Blood sugar is often spoken about as a condition that is “high” or “low.” Patients with diabetes often also have high blood lipids and high blood pressure—all conditions that are measured in the blood and are also referred to as high or low. If a provider discusses two or three of these conditions in an encounter, patients can become confused. Emphasize the difference between sugar, pressure, and lipids and that they are all measured in the blood. This confusion can be compounded if the interpreter or provider misspeak when referring to one of these conditions. So, whenever possible, discuss just one condition per encounter. At some point, employ a teach-back method to ensure that the three concepts are clear for the patient.
- Educate that blood pressure measurement is the basis for diagnosis and monitoring.
- Discuss the importance of taking medication as directed by provider to control hypertension.
- Encourage interpreters to advocate for patients by alerting providers if patients appear confused about hypertension but do not speak up.
- Encourage patients to ask the provider questions.
- MSG is a common ingredient in Asian cooking. Many patients do not know that MSG contains high levels of sodium. Be sure to educate patients about this product when discussing sodium and high blood pressure.
- Talk with patients about traditional treatments they may be using, such as coining.
Reference
Saphonn V, Prak RP: KAP survey on diet and physical activities amongst a household population and students in Cambodia. Ministry of Health, Cambodia; Phnom Penh 2008.